Training Head Start workers to help low-income mothers

Michael Silverstein, a School of Medicine professor of pediatrics, and a team of researchers incorporated a depression prevention technique into Head Start programs around Boston. Photo by Cydney Scott

Depression is one of the most common mental disorders in the United States, affecting over 16 million adults in 2015, according to the National Institute of Mental Health. And when depression strikes mothers, it can negatively affect the entire family. But researchers at Boston University and Boston Medical Center (BMC) are working on a practical solution: a problem-solving intervention that, in a recent JAMA Psychiatry paper, significantly reduced depression symptoms in at-risk mothers.

Michael Silverstein, a School of Medicine professor of pediatrics, and BMC’s associate chief medical officer for research and population health, and his colleagues, carried out a five-year randomized clinical trial on mothers enrolled in Head Start programs around Boston who were at risk of developing depression. The nationwide government program offers low-income mothers of children under five access to social services such as childcare and family wellness and education programs. They found that mothers who learned a technique called “problem-solving education intervention,” or PSE, fared significantly better than their counterparts when it came to avoiding depression symptoms over the course of a year.

According to Silverstein, in the 1990s researchers began to realize that it may be possible to prevent depression with the right interventions. But historically there have been few evidence-based preventive techniques, and such techniques are less available to low-income parents, who already lack access to good mental health care yet tend to suffer from higher rates of depression. And when parents become depressed, it is not only problematic for them, but also for their children.

“Across populations, children who grow up in families with chronically depressed parents have worse social outcomes and academic outcomes and behavioral outcomes,” Silverstein says, and when he and his colleagues interviewed low-income parents around Boston, depression was the issue the parents mentioned over and over again.

The mothers’ feelings of sadness and demoralization largely stemmed from adverse social circumstances beyond their control. Yaminette Diaz-Linhart (SSW’10, SPH’11), a program director at the BMC Center for Family Navigation and Community Health Promotion and a study coauthor , says that previous research has documented higher rates of depression in low-income parents, typically because of the stress of poverty. Another study coauthor, Emily Feinberg (SON’86), a School of Public Health associate professor of community health sciences and a MED associate professor of pediatrics, adds that community violence, homelessness, and lack of support all contribute to higher rates of depression among low-income mothers.

Silverstein and his colleagues wanted to develop a practical, easy-to-deploy approach for preventing depression among low-income mothers. They decided to integrate an intervention into existing Head Start programs, choosing a simple problem-solving technique and training 15 Head Start staff members (none of them a licensed mental health professional) to administer it.

The technique involves six 30-to-60-minute one-on-one sessions where mothers first learn how to articulate the “sticky points” in their lives that make them feel demoralized and stressed. Then, once those daily problems are laid out, the mothers “go through a step-by-step process that involves taking big problems and boiling them down to little problems,” Silverstein says. “What we’ve noticed is that in the first couple of times, our intervention providers are talking a lot and walking people through the process, but by session number four, we’re not really necessary anymore, and so it’s really kind of transferring this skill through this process.”

After an intensive screening process, the researchers selected 230 mothers in six of Boston’s Head Start programs who were deemed at high risk for developing depression. Half of the women learned the problem-solving technique, while the other half received regular Head Start services. Over a 12-month period, the mothers in the problem-solving group had roughly 40 percent fewer depressive symptoms, such as feelings of sadness or problems sleeping.

“We were pretty astounded. We weren’t expecting a result quite like that. I think it confirms the growing sense that depression is a preventable illness,” Silverstein says, adding that the study also demonstrates the value of “looking outside of conventional medical and health venues, outside of doctors’ offices and hospitals,” and tapping a nontraditional workforce of people who are not mental health specialists.

While more research is needed to understand why this problem-solving technique is so good at helping low-income mothers stave off depression, Silverstein speculates that it may reduce stress by teaching mothers how to reframe problems and helping them exert more control over circumstances in their everyday lives. Diaz-Linhart and Feinberg say that the technique could likely transfer to all parents; a previous study Feinberg and Silverstein coauthored in JAMA Pediatrics showed the technique had similarly positive results with mothers of children with autism.

Florida State University clinical psychologist Heather Flynn, who was not involved in the study, is enthusiastic about what it was able to accomplish.

“One of the biggest problems in our field of maternal mental health really is getting treatments that work to people who need them,” she says. “This is very potentially high-impact because of the fact that they were able to find a creative way to get effective treatments embedded within existing services.”

Flynn also points out that mental health specialists are hard to come by in most communities (with Boston being an exception), so it is promising that the researchers successfully trained Head Start workers who were not mental health specialists to administer the intervention.

Next, Silverstein and his team would like to deploy the intervention under more real-world conditions that lack the intense supervision present in a controlled study, to see if the problem-solving technique can be as effective in different contexts and on a larger scale.

“Going where the patients and families are, as sort of part of their day-to-day activities, is a potentially good strategy,” Silverstein says. “But it’s an age-old problem in health care: you find something that has promise; how do you scale it up?”

This is great, rather than focusing on “feelings” the program addresses practical problems in peoples’ lives and works to find solutions. OF COURSE! If your circumstances are challenging, especially if you are feeling helpless or alone, “exerting more control over circumstances in their everyday lives” is the first step toward making things better and thus, feeling better about yourself and your life. Plus the pride of having accomplished your end. I would not even classify this as a clinical intervention, necessarily, note the researcher states it could be generalizable to anyone without a mental health condition. The only possible barrier would be complete apathy on the part of the mother, and I would guess for a mother with a newborn, that might be rare?

ONCE AGAIN, we learn that SELF-DETERMINATION, combined with appropriate assistance and support, is the best panacea.

Yep, “we” know when people feel they have “control” over aspects of their life it is better. It helps the mothers learn coping skills to break down larger problems and thus develop possible solutions, they might actively do, thus provides some control over their lives. Of course.